Description
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Are you a results-driven leader ready to make a meaningful impact to patients, caregivers, and your community? At DMC Detroit Receiving Hospital, we're seeking an innovative and experienced healthcare leader to drive excellence and inspire our team towards exceptional patient outcomes and operational success.
Benefits Statement
At Tenet Healthcare, we understand that our greatest asset is our dedicated team of professionals. That's why we offer more than a job - we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:
- Medical, dental, vision, and life insurance
- 401(k) retirement savings plan with employer match
- Generous paid time off (PTO)
- Career development and continuing education opportunities
- Health savings accounts, healthcare & dependent flexible spending accounts
- Employee Assistance program, Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.
Note: Eligibility for benefits may vary by location and is determined by employment status
Summary Description
Oversees hospital utilization performance improvement and operational management of the site Case Management Department to promote effective utilization of hospital resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughput, and ensure compliance with all state and federal regulations related to case management services.
Integrates national standards for case management scope of services including:
- Utilization Management supporting medical necessity and denial prevention
- Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
- Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
- Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
- Education provided to physicians, patients, families, and caregivers
Responsibilities include the following activities: a) manages department operations to assure effective throughput and reimbursement for services provided, b) leads the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement, c) ensures medical necessity review processes are completed accurately and in compliance with CMS regulations and Tenet policy, d) ensures timely and effective patient transition and planning to support efficient patient throughput, e) implements and monitors processes to prevent payer disputes, f) develops and provides physician education and feedback on hospital utilization, g) ensures compliance with state and federal regulations and TJC accreditation standards, and h) other duties as assigned.
Drafts policy provisions and provides interpretation of department policies, in accordance with the DMC Utilization Review Plan. Identifies the need for and drafts or defines procedures/protocols in collaboration with higher management input, goals, and objectives; modifies procedures/protocols, as necessary. Monitors the quality and productivity of staff to ensure work is completed. Implements performance improvement activities to insure consistency and safety within departmental activities. Initiates or recommends personnel actions such as hires, fires, disciplines, etc. Completes performance appraisals and ensures competency of staff. Assists in the development of daily, monthly, and/or yearly goals and measures for department, and as requested, assists in assessment of goal attainment. Assists in developing and monitoring budget. Monitors activities for and ensures compliance with laws, government regulations, Joint Commission requirements and DMC policies relating to areas of responsibility. As directed, implements external and internal audit recommendations.
POSITION SPECIFIC RESPONSIBILITIES:
Department Operations
- Maintains an adequate number and skill mix over seven days a week to serve the patient population and meet the goals of the department
- Implements and supports with business case staffing requests utilizing the Tenet Case Management staffing recommendations and hospital budgetary guidelines
- Holds regular departmental meetings with staff to provide updates and provides for ongoing education
- Completes initial and annual competency and evaluation review on all case management staff
- Follows the InterQual Inter-rater Reliability (IRR) Policy to determine initial and yearly competency for all employees performing InterQual reviews
- Develops action plan for case managers that fail to meet the IRR acceptable "match" rate to ensure improvement in the accurate application of InterQual criteria
- Ensures new case management staff complete department orientation including review of Tenet Case Management and Compliance policies and Allscripts training.
- Monitors case management processes and staff productivity to ensure medical necessity reviews are completed timely and accurately, payer communications are sent, and authorizations or denials documented and followed up, and that transition planning assessments are completed timely.
Utilization Management
? Implements and monitors processes to ensure medical ne
